The diverse, undersigned individuals and organizations have been meeting regularly over the past year to identify opportunities to help Medicare beneficiaries make better decisions in choosing Part D plans and improve the affordability of coverage that meets their needs. This group includes a range of opinions about the structure of and potential reforms to the Part D program, as well as how the program should pay for prescription drugs. The Draft 2016 Advance Notice and Call Letter provides a vehicle for us to share our views and request the opportunity to work with CMS to improve Part D appeals.

Issue: Making the Exceptions and Appeals Processes More Accessible for Beneficiaries (p. 76-81)

Response: We support CMS’ efforts to make the Part D exceptions and appeals processes more informative and accessible to providers and beneficiaries. In particular, we agree with CMS’ goal to ensure that enrollees and providers receive accurate, clear, and actionable information regarding reasons for coverage denials. Regarding the standardized denial notices (form CMS 10003 (Part C) and form CMS 10146 (Part D)), we support CMS’ focus on improving these notices to plan enrollees and their respective prescribers to provide specific drug coverage denial details. Enrollees are often confused by the current standardized denial notices, and, as noted in the draft Call Letter, fail to exercise their right to appeal the denial. Revising the standardized denial notice to include clear and specific information as to the basis for the denial, the relevant coverage policy and other information needed will enhance an understanding about the denial as well as what additional documentation is needed to support coverage, if appropriate.

Regarding the issue of improved information at the point of sale, we agree in principle that, if an issue cannot be resolved expeditiously by the pharmacist and the PBM, it would be helpful to the beneficiary if they were provided more specific, personalized information for the reason they could not fill their prescription at that time. Currently, this is not provided in the standardized pharmacy notice (form CMS-10147). However, we recognize that at this time there may be systems limitations that prevent better information directly at the pharmacy counter (for example, limitations on characters in what the pharmacy can receive from a PBM/plan that can be provided to a beneficiary), which would need to be considered and addressed. We understand that operational issues to address any improvements would need to be taken into account, and we encourage CMS to continue to explore this option.

Additionally, we appreciate the agency’s openness to exploring multiple avenues to strengthen the Part D appeals process. We urge CMS to establish a multi-stakeholder workgroup (including, but not limited to, Part D plan enrollees, non-profit Medicare consumer advocates, pharmacies, pharmacists, pharmacy benefit managers, Part D plan sponsors, and pharmaceutical manufacturers) to work on developing a streamlined Part D appeals process. We believe this workgroup should fully vet and consider the future improvements and data tracking processes presented by CMS in the draft Call Letter as well as other possibilities.

These possibilities could include several different options, including creation of an appeals data tracking system, enhanced beneficiary notification at the pharmacy counter and allowing the presentation of a prescription and its subsequent denial to serve as (or trigger) a request for a formal coverage determination (which is the first step in the appeals process). As CMS notes, it is important to fully assess both the “benefits and costs” of these policy options, including a careful examination of data sharing considerations as well as possible operational hurdles.

Among the undersigned organizations, we share a commitment to improving the Part D appeals process, both to promote medication adherence and to make the system easier to navigate for people with Medicare. Given this, we believe it would be most productive to discuss how to strengthen Part D appeals in the context of a multi-stakeholder workgroup.

About Karen Fletcher

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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